Читать книгу Hormone Replacement: How to Balance Your Hormones Naturally - Dr. Cabot Sandra - Страница 8
ОглавлениеOver the years there have been many different studies and clinical trials examining HRT. Some have shown that HRT protects against cardiovascular disease, while others have shown that it increases the incidence of blood clots. Some studies have shown that long-term oestrogen, by itself, increases the risk of breast and uterine cancer, and we now know that combined oestrogen and progestin tablets given for over three years also increase the risk of breast cancer.
Major HRT Studies: A Summary
1975 – The New England Journal of Medicine published the results of two major studies that showed that oestrogen given alone (without progestogens) increased the risk of uterine (endometrial) cancer.
1985 – The US Nurse’s Health Study involving 120,000 women found that oestrogen replacement in post-menopausal women reduced the risk of heart disease.
1995 – The US Nurse’s Health Study found that oestrogen increased the risk of breast cancer.
1997 – The Collaborative Group on Hormonal Factors in Breast Cancer found that women on HRT have a three times higher risk of blood clots.
2000 – The National Cancer Institute study found a 40 per cent increase in the risk of breast cancer in women on combined HRT.
2002 – The US Women’s Health Initiative (WHI) Study showed that combined oral HRT increased the risk of blood clots, stroke, cardiovascular disease and breast cancer.
In the 1970s we found that oestrogen given alone increased the risk of uterine cancer, so we then added synthetic progestogens to the oestrogen, to stop this danger. However, in avoiding HRT-induced uterine cancer, we then induced even more dangers – namely an increased risk of breast cancer, cardiovascular disease and blood clots. In other words, by trying to prevent one type of cancer, we have introduced a range of different, unexpected problems. The results of the WHI Study show definitively that when synthetic HRT interferes with the balance of the body’s natural hormones, we can expect adverse effects in a significant number of women.
Oral Combined HRT – No Longer the Gold Standard
Oral combined HRT generally consists of tablets containing natural or equine oestrogens, combined with a synthetic progestogen.
The vast majority of the long-term studies of HRT have been done using hormone tablets, most of them using equine-derived oestrogens and synthetic progestogens. These studies have not examined the long-term risks of natural hormones that are absorbed through the skin, such as gels, creams and patches. Absorption of hormones through the skin is called transdermal absorption, as opposed to oral absorption.
Hormones applied to the skin do not pass through the liver immediately after absorption. There is a huge difference in the metabolic effects of oral hormones compared to hormones that are absorbed through the skin (transdermally).
One of the major reasons that large long-term studies on natural HRT absorbed through the skin have not been done by drug companies is that it is not possible to patent a truly natural hormone. Thus there is no financial incentive for drug companies to do these very expensive studies, as they would never recoup their costs.
Personally I have never felt comfortable prescribing hormone tablets for the long-term treatment of menopausal symptoms. This is because hormone tablets must be broken down by the liver immediately after their absorption from the gut, and thus will exert metabolic changes in the liver. These metabolic changes can increase the production of proteins, including clotting factor proteins by the liver, and this is why HRT given orally will increase the risk of blood clots.
I have also found that oral HRT will cause weight-gain in many women, and that is because it increases the workload of the liver. The healthy liver is the major fat-burning organ in the body; if you increase its workload, there will be less metabolic energy left within the liver cells to burn fat.
Oral combined HRT can increase the incidence of migraines, high blood pressure, high cholesterol, fluid retention and liver and gall bladder problems, once again because of its adverse effect upon liver function.
How It All Started
Many women are now feeling confused, and no doubt somewhat abandoned, as they learn of new controversies about the hormone tablets they take, which drug companies once promised could protect their bones and hearts from the ravages of time.
Well, let’s face it, hormone replacement therapy is nothing new, and has always been controversial, and either in or out of fashion.
Way back in 1889, Professor Charles Edouard Brown-Sequard announced to the French Academy of Sciences that he had injected himself with testicle juice extracted from the pulverized testicles of guinea pigs. He proudly stated that this testicle juice produced a miraculous rejuvenation in his body! At the time of injecting himself he was 72 years old, and his state of physical exhaustion had led him to experiment with a hormonal treatment. He said that, ‘Before I gave myself these injections, I could not work for more than half an hour in the laboratory without having to sit down; even when I was sitting down I felt exhausted after three hours of work. By the third day after starting these injections, all that was changed, and I had recovered my former vigour. I can now without effort or even thinking about it, run up and down the stairs – as I used to do, up to my 60th birthday. After the first two injections, my forearm showed an increase of 6 or 7 kilograms over its previous strength.’
Professor Brown-Sequard was talking about the powerful rejuvenating effect of the hormone testosterone, which was present in abundant amounts in the guinea pigs’ testicles. He also obtained excellent results after injecting ovary juice into women. The Medical Record of 20 June 1889 acknowledged that Brown-Sequard’s discovery was brilliant, if incomplete. Although he was controversial, in many ways he advanced the speciality of hormones, known as endocrinology, and he was a great researcher.
Progesterone was isolated and collected from the ovaries of pigs, and from human placentas, in the early 1930s. In 1938 natural progesterone was first synthesized from the plant hormone diosgenin, by an American biochemist named Russell Marker.
In the 1940s natural forms of HRT were developed mainly by Schering Pharmaceuticals in Germany, and injections containing natural oestrogen, progesterone and testosterone became popular.
Oestrogen therapy first became famous in 1966, when American doctor Dr Robert Wilson, released his best-selling book Feminine Forever, which promoted oestrogen as the elixir of youth. To Dr Wilson, his discovery that oestrogen was able to rejuvenate women’s lives was just as momentous as the replacement of insulin in people with diabetes, who could no longer make insulin themselves. In The Journal of the American Geriatric Society in 1972, Dr Wilson wrote, ‘Breasts and genital organs will not shrivel, and women will be much more pleasant to live with, and will not become dull and unattractive.’ I do not think that Dr Wilson’s comments would be popular with modern-day women – they are decidedly sexist and ageist!
Professor Brown-Sequard and Dr Wilson were correct – hormones are powerful rejuvenators with anti-ageing effects, and many people have had their lives dramatically improved by the use of natural HRT.
Changing Attitudes
Compared to 100 years ago, women now have a much longer life span, and go through the menopause at a relatively young age. This begs the question – ‘Is it really natural to load up every post-menopausal woman’s body with high doses of synthetic hormones for the last 20 to 30 years of her life, just to prevent chronic diseases that may never happen?’
I think to do so is an over-reaction to a normal phase of a woman’s life. You could say this approach is not natural nor physiological, and yet during the past 20 years we have come to see this practice as acceptable and even desirable. I think this idea originated in the mid-1980s when the ‘medicalization of the menopause’ was first promoted. This concept generated fear that women must do something drastic to overcome the ‘disease of the menopause’. In 1985, a special supplement in The Medical Journal of Australia stated that, ‘The post-menopausal climacteric should be regarded as a sex-linked, female dominant, endocrine deficiency disease, with specific symptoms and signs, which should be investigated and managed in a very careful and considered fashion, for the remainder of the woman’s life.’ This concept was promoted to the medical profession, so that doctors started to see the menopause as a disease state, for which they should prescribe therapy. Thus the idea of the menopause as a disease to be feared was passed on to women by their doctors and the media. Women’s attitude towards their own menopause started to change, so that they no longer saw it as a natural phase of their lives. This imposed attitude was a barrier to women seeking to get in touch with their own feelings and reactions towards the menopause. They started to see hot flushes as a symptom of disease, and the term ‘the change’ became synonymous with the beginning of a downward spiral. This atmosphere of fear made many women feel that without dependence upon long-term medicines, their own actions could not have a significant impact on their future health. Thus the mid-1980s was a time of disempowerment for older women. They were mistakenly led to believe that the prevention of the diseases of ageing – namely heart disease and osteoporosis – could only be successfully controlled by HRT, and not with self-help measures such as a healthy diet and lifestyle.
All women were put into the same ‘herd mentality’, and the concept of treating all menopausal women the same was created; in other words, ‘one-brand one-dose of HRT’ was thought to fit all women. The concept of ‘super-market-brand-name-HRT’ became entrenched, and the last 30 years of a woman’s life was now a lucrative commodity.
I was never impressed with this concept, as I could see that many of my patients were unsuited to oral synthetic hormones. My suspicions about oral HRT were confirmed when, as a young doctor in the 1970s, I visited the retirement haven of Miami Beach in the US. During the 1970s, the Premarin brand of oestrogen was the fifth-biggest-selling prescription drug in the US. In Miami Beach I observed thousands of older women enjoying their golden years who had been, or were taking, the fashionable HRT. However, these women did not look healthy – their skins were wrinkled and their postures stooped, and they lacked vitality. Unfortunately the elixir of synthetic hormones could not undo the damage from years of inactivity, smoking and consuming refined processed foods. Interestingly, during the 1980s when I worked in a missionary hospital in northern India, the older women looked much stronger and more youthful than those in Miami Beach, despite a life of hard work, no HRT and nutritional restrictions.
During the 1990s, HRT continued to increase in popularity, and in the year 2000, 46 million prescriptions were written for Premarin (equine oestrogens), making it the second most frequently prescribed medication in the United States, accounting for more than $1 billion in sales, and 22.3 million prescriptions were written for Prempro (Premarin plus Provera). The US Food and Drug Administration approved this type of HRT for the relief of menopausal symptoms and the prevention of osteoporosis, and long-term use of HRT became fashionable to prevent a range of chronic diseases, especially heart disease.
Women Want Choices
All of the millions of women out there who have been happily taking oral combined HRT now find themselves in a dilemma. Many feel they have been misled or abandoned, however the current situation is a reflection of the fact that research takes many years to give us long-term results. Well, we do not want to be research guinea pigs! Now is the time for women to stick together and explore the safest and most natural options. Yes, it is a time where common sense and instincts should prevail, and luckily you do not have to be a rocket scientist to see that there is a world of difference between the different types of HRT now available. Indeed, you do not even have to be a doctor!
This book will take away the fear and confusion surrounding HRT and the menopause, and bring you right up to date. There is no doubt that certain types of HRT can help to slow down the ageing process and improve the quality of your physical, mental and sexual life.
There is no need to give up all hope; some forms of HRT may be able to help you, with minimal risk involved. In other words, you don’t have to throw the baby out with the bath water!
Very few things in life are risk free or come with a 100 per cent guarantee, so let’s get real! We all take a calculated risk every time we drive a car, play sports or, indeed, leave the house. You can even get robbed while you are still at home, and you can never indemnify your life completely. Most of us want to live life to the full and feel challenged, stimulated and sensual, so we take calculated risks every day.
If we can relieve the unpleasant symptoms of the menopause and ageing with effective treatments that do not expose us to unacceptable risks, then we have achieved the best possible compromise. By understanding the ways that natural HRT can be given without upsetting the body’s natural equilibrium, we increase our choices of strategies that will safely improve the quality of our lives.
Some women will not need any HRT, and will need instead a good diet and healthy lifestyle. Other women will find that the menopause and ageing process produce undesirable and/or painful changes in their body and mind, which can only be relieved with some form of natural HRT.
Thankfully, the menopause is no longer ‘the change of life’ that is to be feared. I often reflect upon just how difficult it must have been for women who lived in the early 1900s to cope with these unpleasant symptoms. They must have been very strong women indeed, but strength alone cannot get you through severe hot flushes, insomnia, a desolate sex life, fibromyalgia or a severe emotional imbalance. These women had no choices – no HRT, no anti-depressant medications and probably very little understanding from society, the medical profession or their families.
Today, women have vastly different expectations of life, and do not want to suffer unnecessarily with unpleasant symptoms. They do not want osteoporosis, rapid ageing or an unsatisfying sex life.
Since the 1940s, HRT has gone through many trends, fashions and different types of packaging. We now have so many ways of putting hormones into your body that it is quite incredible! This ranges from hormone tablets, implants, injections, pessaries, vaginal rings, patches, creams, gels, sprays and lozenges (troches). Among all these possible ways of taking HRT, it is now possible to find a safe tailor-made programme of HRT to suit every woman who wants to take HRT.
Thankfully, the woman of today has access to natural HRT, modern-day drugs and nutritional medicines that can alleviate the symptoms that were once considered the hallmark of the beginning of ageing. Yes, we are truly fortunate to be living in this day and age!
The Modern-day Controversy about Hormones
Before the results of the Women’s Health Initiative (WHI) Study were published in August 2002, millions of women in the UK, US and Australia were using some type of HRT.
The use of non-hormonal alternatives for the menopause has also increased. It is true that drug companies have a vested interest in the lucrative baby-boomer generation of women, and it is true that women also have a big interest in a type of HRT that will promise them a better quality of life. However, the baby-boomer generation of women is well educated and discerning, and wants to know the real facts.
Thus, the results of the WHI Study on the effects of combined oral HRT on 16,000-plus women was very timely, and have proven to be a defining moment in medical history that could be considered a bombshell for many researchers in the field of HRT.
The Study uncovered some alarming findings that obviously worry doctors and consumers of HRT. The data and safety monitoring board recommended stopping this trial prematurely because women receiving the active hormones had an increased risk of invasive breast cancer, and an overall measure suggested that the HRT was causing more harm than good. The decision to abandon the trial occurred after an average follow-up period of 5.2 years, although the trial was originally planned to continue for 8.5 years. There were other outcomes that suggested danger, such as an increased risk of coronary heart disease and pulmonary embolism.
Overall, the results of the WHI Study confirmed the growing body of evidence that combination oestrogen/progestin tablets can increase the risk of breast cancer with increasing duration of use, and increase the risk of stroke and blood clots during five years of use. The increased risk of coronary heart disease was largely found during the first year of HRT use. Overall, this American study found that women on combined oestrogen and progestin tablets had a 26 per cent increased relative risk of developing breast cancer, a 29 per cent increase in heart disease, and were 41 per cent more likely to have a stroke. Most of these problems began appearing within the first one to two years of HRT use, but the increased breast cancer risk did not begin until three years of use.
Positive effects of the combined HRT regime were a reduction in the risk of bowel cancer and bone fractures.
In terms of absolute risk, the above figures can be translated into the following statistics – if 10,000 women take combination oral HRT for one year, eight more will get invasive breast cancer, seven more will have heart attacks, eight more will have strokes, and eight more will have blood clots, compared to a similar group of women not taking the hormones. On the plus side, there will be six fewer cases of bowel cancer and five fewer hip fractures.
You can see from these absolute risks of harm, when we look at 10,000 women taking HRT for one year, the risk to an individual woman is not great. However, if we count all the adverse health events that happened over the 5.2 years of the WHI Study, the excess number of adverse events in the women using the HRT was 1 in 100 women. This is a small risk, but shows that risks from combined oral HRT add up over time.
Although the WHI Study was set up originally to demonstrate the ability of HRT to prevent common diseases of ageing, the Study found that the opposite effect appeared to be happening. Given these results, the authors of the Study are recommending that doctors stop prescribing combined oral HRT therapy for long-term use.
Since the results of the WHI Study have caused such a furore, many people are asking questions that will take time to answer definitively – it is possible that future studies will find that the benefits outweigh the risks, perhaps thorugh the use of different combinations or formulations of more natural hormones. For example, studies are needed to determine the long-term benefits of transdermal natural hormones provided as patches or creams. I am confident that these will be shown to be safer than oral combined synthetic HRT, but only time will tell.
Professor Graham Colditz from Harvard Medical School was refreshingly candid about the results of the WHI Study: he said they are a major wake-up call to both consumers and health authorities. Since the WHI Study was abandoned, Professor Colditz and many other health experts around the world no longer recommend the use of long-term combined oral HRT to prevent disease. However, the use of combined oral HRT is still considered as generally safe when used for short-term treatment to relieve menopausal symptoms. My attitude to this is – Why would you use oral synthetic hormones when you have natural hormones that can be given in a more physiological way to relieve the symptoms of menopause?
The results of the WHI Study were based upon using 0.625 mg of Premarin (conjugated equine oestrogen) plus 2.5 mg of Provera (medroxyprogesterone acetate). Other types of oral hormone combinations may have different results. However, three studies using other oral combinations of HRT have all found an increased risk of breast cancer. An Oxford University Study in the mid-90s showed that oral HRT increased the risk of deep vein thrombosis. A long-term study of nurses found a link with breast cancer in 1995, but until now, the risk of combined oral HRT has generally been kept rather low key in mainstream medicine. Well, we have known for years that oral oestrogens such as Premarin, if taken for more than five years, will increase the risk of breast cancer by around 30 per cent. So why has the outcome of the WHI Study created such a bombshell?
It could be partly because the experts cannot seem to agree on the significance of the findings of the WHI Study –
Dr Deborah Grady, Director of the Mount Zion Women’s Health Clinical Research Center at UCLA (University of California in Los Angeles), believes that the results of the WHI Study provide compelling evidence that doctors find a way to get women off oestrogen.
Dr Maura Quinlan, an HRT specialist at the University of Chicago Hospitals, states ‘We have to stop using HRT for healthy women.’
Dr David Dammery, a GP and chairman of the Victorian College of General Practitioners in Australia, is very much against HRT for long-term prevention.
Other well-known professors world-wide believe that the design of the WHI Study was flawed, and that its results are not representative of the true value of HRT in healthy menopausal women. They criticize the sample of women chosen in the WHI Study as being unsuitable candidates for the use of HRT in the prevention of cardiovascular disease. They cite the problem that the sample of women chosen was too old and unhealthy to be used in a primary-prevention trial of the benefits of HRT.
Indeed, 66 per cent of the women in the WHI Study were 60 years or older. One-third of women in the study sample were obese, 36 per cent were being treated for high blood pressure, 12.5 per cent were being treated for high cholesterol, and 50 per cent were ex-smokers. Thus they were not representative of healthy women who had just arrived at menopause. According to these experts, the results of the WHI Study are not meaningful for healthy post-menopausal women. They also point out that there was no increased death rate among the women in the WHI Study who took HRT, compared to those who did not.
What Are the Real Issues?
As a doctor who sees thousands of peri-menopausal women, I believe that it is the quality of life now, and in the immediate future, that is most important to women. This is what women grapple with every day, and it greatly affects the enjoyment of their lives.
Just because certain types of hormones have been found to be unacceptably dangerous for long-term use, does not take away the need for, and interest in, hormone replacement therapy. Women are not so much interested in how they will feel in 20 or 30 years’ time, but rather want to be able to enjoy the still relatively young years, at least in today’s terms, that exist between the ages of 45 to 65. Also, today’s woman is smart and well educated and wants to know ALL her options. She knows that osteoporosis and heart disease have much more to do with diet and lifestyle than with hormones. The reality is this – if you have a poor diet, are overweight, smoke heavily or do not exercise, then all the HRT in the world is no guarantee that you will be saved from diabetes, fractures and heart attacks. Yes, a magic HRT pill to protect us from ageing and disease would be great – I would take it! However, we are all too smart to be duped by the drug companies.
The issues of the moment for peri-menopausal women are:
How do I feel and look today?
How does my mind function?
Do I have energy and vitality?
Do I feel sexual, sensual and feminine?
Can I have a good sexual relationship with my partner?
How can I remain healthy for the next 20 years?
To help women achieve their goals and satisfy the above expectations, doctors have to think laterally, practise holistic medicine and have empathy with every individual woman. If this is not their area of interest, they can always refer to a doctor who is interested in this sub-speciality of medicine. Clinical trials are based upon large numbers of subjects, statistics and a generalized deduction and recommendation. However, many individual women do not really relate to this academic world – it can be frightening and confusing for women trying to relate to the academic ivory tower.
First we must be honest with women – they deserve it! They depend upon doctors and we want to keep their trust.
Women would like to know that:
Very few pharmacological treatments in medicine are perfect – most are a compromise between relief and possible side-effects. We need to weigh up all the pros and cons. If we do take HRT it will have a protective effect upon our bones and usually improve our sex life, however if we use a potent oral form of HRT for more than several years, it may increase our risk of blood clots, strokes and breast cancer.
There is a great difference between individual women – some women need HRT to enjoy their lives, while others feel well and function efficiently without HRT. We should not frighten all women off HRT – some types of HRT remain a viable and safe option for many women.
Nutritional medicine can work, especially for the prevention of long-term degenerative diseases; however it cannot simulate the effect of real hormones in the way we feel. For example, homoeopathic hormones do not work at all, and herbal hormones will not achieve the exact same effect of real hormones.
There is a huge difference in the effect induced in the body by different types of hormones. For example, hormones taken orally, as in the WHI Study, are absorbed from the gut and pass straight to the liver. The liver breaks the hormones down (metabolizes them) and only a certain amount gets past the liver into the general circulation; thus we must use higher doses of more potent hormones to gain a clinical result. This increases the workload of the liver, and induces the liver enzymes to make more clotting factors; thus we become more at risk of blood clots and heart disease. Also, because the progesterone that is commonly used in oral HRT is synthetic, it takes longer to be broken down by the liver, and may accumulate in the body, causing more side-effects. I have never thought that it was physiological (natural) to give hormones by mouth for this reason, unless we require oral contraception. It is much more physiological to give hormones in a way that bypasses the liver. To achieve this, we must administer hormones through the skin (which is called transdermal administration), via implants, sprays, vaginal creams or rings, or injections. Transdermal administration can be achieved by using hormone creams, gels or patches. Some doctors use lozenges (troches) that are designed to be placed between the upper gum and the cheek, so that the hormones they contain are absorbed directly into the blood vessels under the lining of the cheek. This way we are meant to avoid swallowing the hormones and thus absorbing them from the gut and then through the liver. Some women tell me that it is difficult to avoid swallowing some of the lozenge, especially since they come in several hundred delicious flavours!I personally feel more comfortable prescribing transdermally-absorbed hormones via the creams and/or patches, especially for long-term use or for women with risk factors for HRT. The beauty of the creams is that they can be tailor-made for the individual woman, to contain the combination of natural hormones that she needs as determined by her blood tests, medical examination and history.
Although there are some very favourable clinical trials evaluating the use of hormone creams for various hormonal problems, there are no very long-term studies available on their safety for use as HRT for the post-menopause.
The use of any form of HRT is the choice of the patient, and it must be based upon informed consent. Women need to know that we cannot give them 100 per cent guarantees of safety, and that, generally speaking, it is wise to find the lowest dose of HRT that will relieve unpleasant symptoms and improve well-being. This can be compared to taking the oral contraceptive pill – women know about the risks, as they are printed on the packet. However, millions of women choose to take the Pill, because its advantages often outweigh the disadvantages in the individual woman.
Communication is the key – doctors need to treat women as intelligent human beings. Women need to take some responsibility in helping their doctor to decide if they will use HRT. They can only do this if they know and understand all their options. Luckily you do not have to be a rocket scientist to work out the advantages of different types of HRT. Common sense and realistic expectations should be explored. It is always possible to prescribe HRT for a short period (less than a one year), choosing a transdermal application just to see if it really makes a difference. Then you can weigh up the absolute risks, if any, of long-term use before deciding whether to continue.
Just because yet another hormone controversy has raised its head does not mean that all women will stop wanting to take HRT. Today’s menopausal woman has a much longer life span, and totally different expectations of life, than women who lived 100 years ago. She does not want to –
age rapidly
stop being sexually alive
embrace old age mentally and physically at the tender age of 50.
There is no doubt that hormones can help us feel and look younger and keep us sexually young. Just imagine if men ran out of their sex hormones at the tender age of 50 – well, there would be a hormone shop in every suburb!
Yes, ‘hormones make the world go round’ and, controversial or not, they are not going to become strictly taboo!
